|Year : 2016 | Volume
| Issue : 2 | Page : 53-57
Sialoendoscopy: A retrospective review of our outcomes
Hesham Yousif Ali1, Shilpa Prabhu2, Muneera Alkhalifa3
1 HOD and Consultant, Department of Otorhinolaryngology, BDF Hospital, Kingdom of Bahrain
2 Senior resident, Department of Otorhinolaryngology, BDF Hospital, Kingdom of Bahrain
3 Resident, Department of Otorhinolaryngology, BDF Hospital, Kingdom of Bahrain
|Date of Web Publication||6-Jan-2020|
MBBS Muneera Alkhalifa
Department of Otorhinolaryngology, BDF Hospital
Kingdom of Bahrain
Source of Support: None, Conflict of Interest: None
Sialopathologies are among the most interesting cases an otorhinolaryngologist frequently deals with. Sialendoscopy is an image-guided minimally invasive technology utilizing miniature endoscopes and variety of instruments suited to deal with salivary gland pathologies in incision less manner. It can be applied in diagnostic and interventional manner. In our current study we aim to review the different type of pathologies encountered in our practice and the overall outcome for the different sialendoscopic interventional modalities utilized.
Setting: Retrospective observational study.
Materials and Methods: All the traceable medical records of patients who underwent sialendoscopy between March 2008 and October 2015 were reviewed and data were analyzed in respect to demographic nature of cases, salivary glands affected, type of pathologies encountered, treatment modalities used and operative details.
Results: Thirty-four glands in 33 patients who underwent sialoendoscopy were reviewed with 1.7:1 female to male ratio, mean age was found to be 43 years (7-81 years). Average stone size 5.7mm. In our series, diagnostic and therapeutic outcomes were quite satisfactory with success rates of 97% and 82.3% respectively. Laser sialo- lithotripsy was used successfully in 5 cases (14.7%) while combined approach was successfully utilized in 9 cases (26.5%).
Minor complications encountered in 15% of cases included basket impaction in 2 cases (5.9%) and postoperative infection in 3 cases (8.8%). Single case of major complication airway obstruction (2.9%) encountered early in adopting the technology. All complications were managed successful with no long lasting morbidity.
Conclusion: Sialoendoscopy is an effective and safe minimal invasive technique than can be utilized for diagnostic and therapeutic purposes.
Keywords: Sialoendoscopy, salivary glands, sialolithiasis
|How to cite this article:|
Ali HY, Prabhu S, Alkhalifa M. Sialoendoscopy: A retrospective review of our outcomes. Saudi J Otorhinolaryngol Head Neck Surg 2016;18:53-7
|How to cite this URL:|
Ali HY, Prabhu S, Alkhalifa M. Sialoendoscopy: A retrospective review of our outcomes. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2016 [cited 2021 May 5];18:53-7. Available from: https://www.sjohns.org/text.asp?2016/18/2/53/275264
| Introduction|| |
Sialopathologies are among the most interesting cases an otorhinolaryngologist frequently deals with. They can be divided into two types those of tumor nature affecting the parenchyma or pathologies affecting the ductal system. The latter is more frequently encountered in the form of stones, strictures, or polyps .
Sialendoscopy is a minimally invasive diagnostic and therapeutic technology aiding in the management of obstructive pathologies of the salivary glands . This technique has gained popularity for diagnosing and relieving obstructive pathologies in the major salivary glands  which can be done under local anesthesia adding to its cost effectiveness .
In our current study we aimed to review the different type of pathologies encountered in our practice and the overall outcome for the different sialendoscopic interventional modalities utilized.
| Materials|| |
Thirty four glands in thirty three patients who underwent sialendoscopy in the period between March 2008 and October 2015 were enrolled in the study. In one patient two glands were scoped in the same setting. The mean age of the sample was 43 years old (age range 7-81 years) with a female to male ratio of 1.7:1 (21 females and 12 males). The main indications for the procedure were symptoms and signs suggestive of an underlying intermittent obstructive salivary gland pathology, so- called “meal-time syndrome”, and history of recurrent sialadenitis. The procedure was delayed for patients who presented with picture consistent with acute sialoadenitis .
| Methods|| |
A retrospective study of 33 patients (34 glands) who underwent sialoendoscopy performed by the senior author in the period between March 2008 and October 2015 was reviewed. Patient’s demographic data, type of anesthesia used, type of pathology, stone size, number, site, outcomes and complications were all documented. CT scan was performed for all 33 patients prior to procedure to help planning the procedure and identifying number, size and location of stones if present and additionally to exclude other pathologies [Figure 1].
|Figure 1: Plain CT scans showing right submandibular gland stone in axial, coronal and sagittal view respectively.|
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Duct punctum was identified using methylene blue dye to facilitate its identification by visualizing the methylene blue salivary washout effect under the microscope [Figure 2]a. Then 10 or 20 percent local anesthesia with adrenaline (1:100,000) was given to the region surrounding the papilla (only cases of submandibular gland sialendoscopy) to help to stent and stiffen the punctum to help subsequent manipulation. Xylocaine spray externally was found to be enough to achieve satisfactory anesthesia when procedure conducted under local anesthesia, only rarely was needed to be irrigated intraductally [Figure 2]b. Sequential dilation starting with salivary probe size 0000 diameter until 0 [Figure 2]c, followed by introduction of the dilator [Figure 2]d. Further dilation took place by the further introduction of gradual bigger size dilators starting from 1 until 8. The size of the punctum rendered large enough to administer the diagnostic sialendoscope [Figure 2]e and the exploration of the ductal system took place under continuous normal saline rinsing via the irrigation channel incorporated within the scope probe [Figure 2]g. Subsequently, interventional sialendoscopy is tailored in favor of the use of laser fibers, stone baskets, forceps, or balloon dilators depending on the pathology encountered through working channel [Figure 2]f.
|Figure 2: (2a): Duct punctum was identified using methylene blue dye, (2b): 10 or 20 percent local anesthesia given to the papilla with an anesthetic paste or spray, (2c): Salivary probe of size 0000 to 0 introduced, (2d): the dilator introduced and introduction of increasing size probes-size 1 to 8, (2e): introduction of sialendoscope, (2f): extraction of stones via wire basket.|
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| Results|| |
Thirty three patients (34 glands) were enrolled in the study with a mean age of 43 years (age ranging 7- 81 years) with a female to male ratio 1.7:1. Thirty-Four sialoendoscopies were preformed (one patient had two sialoendoscopies) among which 6 cases (17.6 %) were performed under local anesthesia within clinic or day care setting, while the rest were done under general anesthesia as dictated by the nature of the pathology suspected. Stones were encountered in 57% of the cases of obstructive pathologies, followed by punctal stricture 18%, co-existent stones and ductal stricture 9%, and mucus plugs and other causers 16%.
The average stone size 5.7mm (ranging from 2.5 mm to 20 mm). Single stone was encountered in 69% of the stones cases, two stones in 13%, three and more stones in 18%. Submandibular glands were affected in 22 cases (64.7%) while the Parotid gland in 12 (35.3%). Combined approach was used in 9 cases (26.4%) and Laser lithotripsy was used in 5 cases (14.7%), the techniques both of which were reserved for bigger stones not amenable for removal in one piece through the natural punctum.
Successful diagnostic sialendoscopy was the outcome in 33 glands (97% success rate) as in one case we failed to identify punctum during the initial phase of introducing the technique in our service. Among the 28 interventional sialoendoscopies, the successful outcome 82.3%, successful outcome being defined as relieving the obstructive pathology and relieving patients’ symptoms.
Single case of major complication airway obstruction (2.9%) was encountered early in adopting the technology, which mandates ICU admission for a day. Minor complications encountered in 5 cases (14.7%) of cases included basket impaction in 2 cases (5.9%) and postoperative infection in 3 cases (8.8%). All complications were managed successfully with no long lasting morbidity.
| Discussion|| |
Sialendoscopy is a living example of the changing landscape in our specialty by creating a shift in the paradigm of surgical approach. The innovations in the quickly advancing technology have served our specialty remarkably by making minimal invasive surgery readily available for the benefit of our patients. Such approaches have facilitated our thinking process about pathologies and have resolved many of the complications inherent in the open approaches . Hippocrates first described salivary gland diseases in 460-370 BC .
More recently, the trials to perform salivary endoscopy in the early 1990’s by Katz and Gundlach were not widely accepted most likely due to poor visibility of the proto scopes or possibly due to lack of specific instrumentation. It was not before 1994 when Nahlieli et al  performed successfully an endoscopic retrieval of stones using a hazel-type of scope. The technology was further refined by Marchal et al .
Recurrent sialadenitis manifested with pain and swelling of the major salivary glands, is a common presentation for salivary gland pathologies. Among the incriminated etiologies of sialadenitis obstructive pathologies of the salivary ductal system are most common. Salivary calculi score an incidence of 1.2% and account for 60-70% of all salivary duct obstructions. Various hypotheses were formulated to propose their formation; the first postulated the existence of intracellular micro- calculi, which as get excreted in the ductal system, plays the role of a nidus for further calcification .. The second theory presumes that ‘mucous plug’ instead is nidus.
Other theories proposed the retrograde nature of the nidus, claiming it to be substances or bacteria migrating from the oral cavity into the salivary gland . Irrespective of the nature of the nidus, all theories agreed in believing that the initial nidus will grow bigger by depositing progressive layer of inorganic and organic substances .
Rauch. et al. autopsy studies found out that sialolithiasis affect 1% of Salivary glands. Such autopsic rate is far higher than the admission rates related to stones in England as per study by Escudier and McGurk who estimated the incidence accordingly to be between 1/15,000 and 1/30,000. However, such underestimated frequency could be explained on the grounds of the poor available diagnostic tools represented outdated detection methods and limited therapeutic options for intraglandular stones, leading to more conservative approaches .
According to the literature, salivary stones are localized predominantly in the submandibular gland in up to 80% to 90% of cases 6. However, more recently, Marchal et al  found parotid glands to be affected more frequently than thought before (30% to 40%); a difference could be accounted by the sensitivity of the new detection methods. In our study, our findings corresponded well with Marchal results; 64.7% for the submandibular and 35.3% for the parotid glands.
Sialoliths are composed mostly of varying ratios of organic and inorganic substances. The organic substances are usually in the form of glycoproteins, muco-polysaccharides and cellular debris, while the inorganic substances are composed mostly of calcium carbonates and calcium phosphates . In our study 4 patients agreed for testing the contents of stone which showed carbapatite calcium phosphate structure with traces of oxalate in it. Bacteria role in forming the nidus were highly suggested by electron microscopic scanning and more recently by polymerase chain reaction (PCR) which demonstrated the presence of bacterial DNA .
Tobacco smoking is said to affect the composition of saliva in many ways, In a recent study, it was found that it would result in an increased cytotoxic activity, a decreased polymorphonuclear phagocytic ability, a reduced salivary amylase, as well as a reduction of salivary protecting proteins, such as peroxidase, all of which can theoretically impair the phagocytic and protective functions of saliva, with resultant higher chances of infection and subsequent sialithiasis formati on . In our study 4 patients among 33 were smoking tobacco.
In our study, stones were found in 94.1% (32 cases) and 22.8% (8 cases) had strictures. According to a study done by Nahlieli et. Al  60-70% of salivary duct obstruction was due to calculi, while strictures accounted for 34-19%, inflammation (5-10%) and other rare pathologies (1%).
In our population multiple stones were found almost in a third of the cases (31%) of the cases. Multiple calculi were detected in 37 of 530 consecutive investigated sialolithiasis cases by Ardekain L et al .
Salivary calculi are usually small and measure from 1 mm to less than 1 cm. They rarely measure more than 1.5 cm. Mean size is reported as 6 to 9 mm. Giant sialoliths are rare and defined as the size of 3.5 cm or larger .
Depending on their size, stones can either be floating in the lumen, partially fixed due to irregular shapes or even can be extremely attached to the ductal wall. In some cases, they are trapped behind a bifurcation. Their annual growth rate has been estimated at 1 mm per year .
Marchal et al stated the average size of the sialoliths is 3.2 mm and 4.9 mm, for parotid and submandibular stones, respectively . Leurs et al reported that the greatest predictor of successful sialendoscopy was stone mobility . Stone size smaller than 5 mm resulted in an 80% removal rate, and stones smaller than 4 mm resulted in 91% removed. In our experience, average size of stone was 5.7mm, larger average size of stones in our population can be explained by late presentation or delayed referral, which itself could have influenced negatively our overall successful interventional outcome.
Large salivary stones or impassably dense strictures have always posed a therapeutic challenge that could not be solved by sialendoscopy alone. In all these cases, removal of the gland was the last-resort option, which is known to be associated with a significant rate of morbidity. Therefore, a new combined approach using both sialendoscopy and external surgery was developed . In our study we used combined approach in 26.4% (9 cases) of cases.
In cases of bigger stones, prior fragmentation is necessary using a laser system. The first successful endoscopic-guided laser lithotripsy of salivary stones was reported by Gundlach in Germany . Limitations are stones that are only partially visible, or calculi too large in size. In our experience Homium Yag sialo- lithotripsy was attempted successful in 5 cases (14.7%). With respect to diagnostic sialendoscopy, Marchal and Dulguerov reported a 98% success rate in 450 cases , whereas Nahlieli et al reported 96% in their case series17. Our successful diagnostic sialendoscopy was 97% success rate, which is well keeping with literature. Interventionally, Nahlieli et al reported success rates of 86% and 89% for endoscopic parotid and submandibular sialolithotomy, respectively, in 736 cases of sialolithiasis . In our study, among the 28 interventional sialoendoscopies performed our successful outcome was 82.3% successful outcome being defined as relieving the obstructive pathology and relieving patients’ symptoms. Our lower success rate can be explained by the bigger average stone size found in our study. Leurs et al finding that the greatest predictor of successful sialendoscopy was stone mobility and size. Stone size smaller than 5 mm resulted in 80% removal rate, and stones smaller than 4 mm resulted in 91% removed .
Single case of major complication airway obstruction (2.9%) was encountered early in adopting the technology, which mandated ICU admission for a day. Minor complications encountered in 5 cases (14.7%); included basket impaction in 2 cases (5.9%) and postoperative infection in 3 cases (8.8%). All complications were managed successfully with no long lasting morbidity.
| Conclusion|| |
Sialoendoscopy is an effective and safe minimal invasive technique than can be utilized for diagnostic and therapeutic purposes.
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[Figure 1], [Figure 2]